Job Summary

We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.

Primary Responsibilities

Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
Communicate directly with requesting providers during peer-to-peer discussions.
Document clinical determinations and rationale clearly and concisely.
Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
Participate in committee meetings, audits, and quality improvement initiatives as needed.

Education and Experience

MD or DO degree from an accredited medical school.
Current, unrestricted medical license in the United States.
Board certification in a medical specialty.
Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
Prior experience with appeals, grievances, or peer review is highly desirable.
Excellent communication and clinical documentation skills.
Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).

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